Arbors at Minerva

In the surveyor’s words

From the most serious findings on record at Arbors at Minerva, in the surveyor’s own words.

• Actual harm, isolatedF684Jan 23, 2025

  Based on record review, emergency medical services (EMS) run report review, death certificate review, policy review, and interview, the facility failed to adequately monitor and provide timely and necessary care and treatment following a change in condition for Resident #1. This affected one (Resident#1) of three reviewed for change in condition. Actual Harm occurred on [DATE] at 1:48 A.M. when Resident #1 (who had previously been medicated for nausea/vomiting on [DATE] at 3:56 P.M. and 10:38 P.M.) vomited brown-colored emesis and had a decline in her baseline vital signs. […]

• Actual harm, isolatedF600Aug 17, 2023

  Based on facility Self-Reported Incident (SRI) review, medical record review, interview, and facility policy review, the facility failed to ensure residents were free from staff to resident verbal, physical, and sexual abuse. This affected two residents (#35 and #50) of three residents reviewed for abuse. Actual Psychosocial Harm occurred in August 2023 (exact date unknown) to Resident #35 when State tested Nurse Aide (STNA) #76 told him to scoot your fat a$$ back in the chair, move your fu### legs. Resident #35 was upset. Additionally, on another occasion, date unknown, STNA #76 flung Resident #35's legs into the bed. STNA #76 stretched his legs out and flung them in the bed. Resident #35 told STNA #76 it hurt when she did that. […]

• Actual harm, isolatedF689Apr 3, 2023

  Based on record review and interview the facility failed to provide adequate assistance, including appropriate lower extremity support during transport of Resident #3 (with hemiparesis/hemiplegia to the right side) in a wheelchair. This affected one resident (Resident #3) of one resident reviewed for a fall with major injury. The facility census was 70. Actual Harm occurred to Resident #3 on 02/20/23 when staff failed to provide adequate lower extremity support to the resident during transport resulting in the resident's leg dragging on the floor and the resident falling from the wheelchair and suffering a right clavicle fracture and proximal humeral fracture. […]

• Actual harm, isolatedF689Jun 22, 2021

  Based on observation, record review, policy and procedure review and interview the facility failed to implement individualized and effective fall risk safety interventions for Resident #3, who was cognitively impaired and at risk for falls to prevent falls including a fall with injury. Actual Harm occurred on 06/10/21 when Resident #3, who had a history of turning off her bed safety alarm, fell out of bed, when the alarm was off, resulting in a spiral fracture of the shaft of the right tibia and fibula requiring hospitalization . This affected one resident (#3) of three residents reviewed for falls. […]

• No harm, potential for more than minimal, widespreadF730Aug 22, 2024

  Based on employee file review, staff interview and review of facility policy, the facility failed to ensure State tested Nursing Assistants (STNAs) had evaluations completed as required. This had the potential to affect all 69 residents residing in the facility. Findings Include: Review of the employee file for State tested Nursing Assistant (STNA) #274 revealed a hire date of 06/14/23. No annual performance evaluation was found. Review of the employee file for STNA #219 revealed a hire date of 08/17/22. No annual performance evaluation was found. Review of the employee file for STNA #501 revealed a hire date of 02/2024. A 90-day performance evaluation was not found. Interview on 08/22/24 at 12:30 P.M. […]